MaxedOutMama

Sunday, November 29, 2009

It Was A Working Holiday

Through a series of flights, drives etc, my immediate family all managed to end up together for Thanksgiving in the Ne. That was the great part. The weather was not great.

The difficult part was that my brother the TechnoBuddha was scheduled (while he was in the area) for a checkup with the doc. That's my doc - SuperDoc. And I had gotten the Chief an appointment with SuperDoc the day after Thanksgiving. (SuperDoc seems afraid to take more than one day off at a time, I suppose because when you are a SuperDoc you don't like abandoning your medical salvage projects to lesser docs.)

I had tested TechnoBuddha's blood sugar in April while he was with me for Easter, and he was close to veering into Type II. So I then gave him a series of instructions and shipped him off to SuperDoc, and this was a followup for that. (TechnoBuddha has lost a TON of weight since then, and is progressing nicely with his exercise program, and his blood sugars have plummeted way out of the iffy range.)

So when TechnoBuddha arrived for his appointment at 7:30 AM (SuperDoc likes to crank them through early, which leaves more time for screaming at insurance companies all afternoon, I suppose), he discovered a very frantic SuperDoc whose network was down. Apparently the guy who normally works on it fled to Europe or went there on vacation or something.. So TechnoBuddha spent most the day on Wednesday getting him at least up, which finally involved buying new cable to connect the server and the router and reprogramming the router (which cable is now duct-taped across the back office). The router was new. The network is totally undocumented - even the cables are unlabeled, and you just can't start pulling cables at random to find out what is connected to what..

SuperDoc asked TechnoBuddha to come back on Friday to fix some other problems with two computers (Vista) that had apparently never been working right since they were put in.

So TechnoBuddha asked me to come with him on Friday to work on the problem, which was pretty dire. If I had been trying to work on those two machines, and if I were not computer literate, their broken and bleeding carcasses would long ago have been found by the side of a country road. I would have considered it justifiable homocide in self-defense. Those two PCs were a crime against humanity, and I am not exaggerating.

And we were at it most of Friday before we traced enough of the network to find where everything was hooking up and what the problem really was. I am sure we looked like a couple of bumbling idiots, but when there is no documentation and no cable labelling it is hard to even find the device locations much less figure out what to change, so I spent considerable time crawling around on the floor looking at connections. Commandments 1 - 10 of dealing with computer problems can be summed up with "Always wear pants and comfortable shoes". Friday night late I downloaded manuals and researched enough to figure out possible fixes for the problem, but Saturday we ended up pinging all possible addresses to find the freakin' IP addresses to get in there to get the information we needed to fix the freakin' problem.

Both Friday and Saturday we had to do all of this while the office was running and treating patients, so it was hardly an ideal situation.

We did finish those two machines on Saturday. I think whoever fled to Europe might not want to come back. SuperDoc had been instructed to buy Windows 7 and put it on the two machines which were so problematic, but that wouldn't have fixed the problem - IMO it was the way that they were hooked up to the network devices that appeared to be causing most of the nightmare. SuperDoc is having Comcast come in to rewire the building in a few weeks, so that may help. However his network has other problems - it needs to be documented and have a bunch of things done to it for safe operation. I am writing up all of what we did and learned, and there is a lot that still needs to be done.

Of course in the middle of this, SuperDoc had looked at the Chief's records from his recent hospitalization (which were not easy to get). The Chief has an emergency appointment at the hospital up here tomorrow, because according to SuperDoc the Chief was treated by "A person with an elementary school education and a cardiologist's degree" in South Georgia. SuperDoc said it was clear that even the hospitalist had doubts, and SuperDoc advised me that it could have been possibly lethal if I had not shooed the Chief in for his SuperDoc grease and oil job. SuperDoc hasn't said much, but he seems quite agitated and he told me to be sure to go in and talk to the doctor at the hospital. So I am nervous.

Tomorrow morning early I have to go to SuperDoc's to make sure his network comes up properly, and then I rush back and get the Chief and go to the hospital. As soon as I get a clear Chief day, I have to go back to SuperDoc's and work on his computer situation some more.

So you can safely assume that blogging will be light this week. SuperDoc and the Chief come first. More than a decade ago SuperDoc administered medication to me to try to save my failing brain. He opened up his office every day for months to do it - including Sundays. Including Easter Sunday. My situation then was totally dire, and I was one of those salvage projects. I would crawl across broken glass for SuperDoc, and I know darned well he isn't earning much. He has old-fashioned medical principles and does a lot of free medical care. He won't take most Medicaid patients, because it costs him more to treat them than if he were doing it for free, but he will treat people for free, including people like me that current medical protocols consign to the "untreatable" category. There is a divine sort of symmetry involved in applying my salvaged brain to straighten out his computer situation. SuperDoc said quite plaintively that he had had about five people in to work on it, but of course you will not get good results when the thing is undocumented. .

Before I get back to network diagrams, I would like to point out this profoundly stupid op-ed by Nicholas Kristof in the NY Times Are We Going To Let John Die?. I do not believe that even the SuperDoc and the Shrink combined could sort out Kristof's mind - I think this is self-inflicted, willed mental suicide in action. The basic points are:

This guy named John in Oregon has a very nasty growth of abnormal blood vessels in his brain. More general info here.

The only real treatment to stop the pain and the incremental brain damage is brain surgery.

But John can't get brain surgery, because, according to the OP-ED: Without insurance, John has been unable to get surgery or even help managing the pain. When he collapses or suffers particularly excruciating headaches, Esther rushes him to the emergency room of one hospital or another, but an E.R. can’t do much for him. One hospital has told them not to come back unless he gets insurance, they say.

Kristof wants those senators raising questions about health care reform to feel very guilty, repent and immediately vote for it, because: If a senator strolled indifferently by as John retched in pain, we would think that person pitiless. But isn’t it just as monstrous for politicians to avert their eyes, make excuses and deny coverage to innumerable Americans just like John?

John's story is very heart rending, and one may feel that Kristof has a point, until you read on and learn that that John is now covered by Oregon's Medicaid program, which fact Kristof includes but does not seem to assimilate:

He hasn’t been able to find a doctor who will accept him as a patient for surgery, apparently because the reimbursements are so low. Doctors tell him that his condition is operable — but that they can’t accept him without conventional insurance.

I am extremely sympathetic to John, considering that I too, know what it is to vomit because the headache is so bad. My last such episode was not that long ago. Last night I only slept about four hours because I was in so much pain. Pain is a feature of my daily life. I do not suffer, but I do feel pain and my body experiences the stress of it. However, what I get (and what John is not getting) is the best possible treatment that gives me the maximum of achievable functionality. I wouldn't be getting that care if I were on Medicaid, which explains some of my hostility to these bills.

But what is Kristof's point? Does Kristof know himself? The facts of this case seem to justify the senators who are asking questions and demurring on the health care bill rather than those who are willing to go ahead with it.

Under any of the current bills I've read (which is why I read them), John's coverage would not change as a result of the bill. He'd still have Medicaid; whatever his current situation, it would continue as is. If anything, some of these bills would make John's situation much, much worse due to the liability problem and the failure to pass tort reform. See NOFP's post on the subject. NOFP quotes Critical Care:

Section 261 (p. 149–150) of Speaker Pelosi's bill puts physicians in an impossible conundrum. Doctors will only be reimbursed that amount for which the health-care commissioner determines is the appropriate treatment for a particular set of symptoms. However, doctors may still be held legally liable for failing to give that care which they could or should have given if additional care is actually more appropriate for the patient's well being.

So doctors are left with a choice between providing care that they know will benefit the patient but for which they may not be reimbursed, or providing limited care for which they will be reimbursed but quite possibly also sued by the patient.

And that is a big part of why John is not getting the surgery he needs, and a big part of why many doctors will do free work, but not Medicaid work, and won't be able to do much for certain patients that they would otherwise treat. If patients won't get the ancillary care because it is not funded by public insurance, it is useless to perform a dangerous operation. And unless a surgeon can get a hospital and other doctors to commit to performing the extra care, it may be very dangerous to operate on the patient and leave him in worse condition. And that would expose the doctor to a lawsuit - word has it John Edwards has some pretty big alimony to pay and that he is looking for just such patients. Medicaid reimbursements are frequently so low that a doctor does not just lose money on the time spent treating them, but if a doctor accepts a lot of Medicaid patients, that doctor may not be able to afford the cost of the malpractice insurance to cover them. (Malpractice premiums vary by specialty and by patient count.) Still, I think there is something wrong with the story as told in this column. I am pretty sure that John can get treatment in Oregon provided his condition seems treatable.

Perhaps you all may now better understand why I am so concerned about these bills, and why I may end up leaving this country if they pass in order to go to a country that doesn't have universal care and in which I can pay for my own care. Without tort reform, patients such as John and myself are likely to be in more jeopardy rather than less. With tort reform, we are liable to have expanded access to high-quality health care. See Nixon's column on medical liability and Christus Health's experience. Please note that while Massachusett's health reform attempts have produced patients without doctors and in many cases cuts in services provided specifically for those on public insurance, tort reform in Texas has produced more doctors, expanded access, and more services for people like John.

Obviously I would wish not to have the disease I do have. Unfortunately, some of the results of the disease I have are so similar to John's problem that I found it very painful to read of his situation. But I have been treated, and it is largely because I was wise enough never to fall for the sucker bait that is public insurance. It is a lie.

However, because I have been so ill, I have spent a great deal of time exposed to doctors, and the one thing I can tell you is that most of them are very good. They also like to do it. If you remove the impediments (such as crashed networks), they doc. If you just get out of their way, they doc. If you just promise not to sue them, they doc. Doctoring is what they do. The better they are, the more fanatical they are about it - and the US has some incredibly good doctors and a large mass of exceedingly good doctors. The US has doctors so damned committed to treating their patients that they have stripped themselves of all their assets and continued to treat patients without malpractice insurance. Obviously, the limit there is on how good the doc's marriage is. I do not think we wish to perpetuate a system in which the only doctors who can continue to treat large numbers of high-risk patients are those with extremely good marriages.

When even a profoundly altruistic SuperDoc has to draw the line at taking Medicaid patients that he cannot treat effectively because they will not get ancillary care, and they cost more for him to treat than free patients, one must understand that the FIRST step in health care reform should be to change our medical torts system.

These are health care reforms that will not work:Payment by diagnosis rather than payment for service. ( This is what just happened to the Chief down in GA. He got the amount of treatment that would be reimbursed, and no more. No use ranting about private insurance companies - he is considerably older than me and is now on Medicare )Mandated practice standards by some stupid government board. Guidelines are helpful, but in fact medicine is highly individual. All this BS about medical boards is going to be worse than useless - it will be used as a means to deny care to those who need it most (like John).Paying doctors less if their patients are more expensive. This punishes doctors who are ordinarily the best in their particular specialities. These doctors are known to other doctors, who refer them their difficult cases. SuperDoc is on such a list, and I notice he seems to be treating a lot of other doctors. Needless to say, those cases may require more diagnostics and more treatment than the average person with that particular named condition. However, the rewards and cost-savings of effective treatment (such as I received) are disproportionate as well. Medicaid would have paid for me to die very slowly and expensively, but it will not pay for the rather inexpensive treatment (generally less than 4K a year) that allows me to run around and fix desperate SuperDoc's computers so he can doc. Of course, it is so cheap because the doc trained me in some stuff that is often done by medical personnel, but still, there is something wrong with this.Allowing insurance or boards to mandate which tests/diagnostics should be used: TechnoBuddha had useless surgery this summer for precisely this reason. Because of a possible problem, SuperDoc wanted to send him for certain tests before letting him ramp up the exercise. One of them the insurance company would not pay for - they wanted him to have another, more expensive test which their guidelines said was better. However, for some SuperDoc reason that I do not understand, SuperDoc knew that test was usually better but was likely to generate a false positive in TechnoBuddha's case. But SuperDoc could not get through to anyone at the insurance company who could understand what he was saying, so TechnoBuddha had the insurance company's test, it rendered a false positive, and TechnoBuddha then had useless surgery to treat the condition that he did not have. At some point, we just need to all give up and realize that if our doctors are that incompetent, insurance companies fiddling are bound to make it worse rather than better. (The GIGO principle rules the world. If the average doctor is incompetent, the information pool used to generate the guidelines will also be skewed. Sometimes doctors use the inexpensive, old-fashioned test FOR A REASON.)Mandating that unneeded coverage be purchased. We have accepted the reality that we can't provide cheap Cadillac medical treatment to everyone. Thus, should the federal government be requiring that everyone purchase coverage for, say, in vitro fertilization? It strikes me that such coverage is quite useless for persons such as the Chief and I. And mandating certain dollar levels of coverage is stupid too; it makes all medical care cost more. The old major medical policies were far more cost effective. If poorer people cannot afford the initial costs of regular treatment, then the obvious way to deal with that is to directly fund them individually, rather than making the entire population adopt an economically inefficient method of paying for health care. One of the reasons we had to work all weekend to deal with SuperDoc's computers is that a staggering amount of software, manpower and electronic filings are needed just to deal with simple doctor's visits. That is one of the reasons why going to a doctor costs so much more than it used to.Setting up a vast medical bureacracy. Krauthammer's comments on the Senate health care bill cover this issue well. I found the bill unexpectedly arresting - comic even - and spent some rather happy hours calculating the total cost before the news of the Chief's premature clearance came through. If all those boards and new studies are going to be properly funded, they would cost over a hundred billion dollars. I suspect they won't be, which will produce more medical dogma garbage, but it will still cost a lot. Every dollar you spend on overhead is a dollar not spent treating a person.

I hope I have added something to this debate. Perhaps not. However I do know that the time I spent on the SuperDoc's floor fumbling around with cables at least allowed him to continue to treat patients.

Kristof's dingbat column has an accompanying blog post. I found reading the comments to be an exercise in disbelief; almost no one comments on the fact that the man has insurance already or the other discrepancies. Here is one exception:

I am not completely certain but I believe your column distorts the facts. Under EMTALA a hospital cannot mandate insurance coverage as a condition of treatment. Under HIPAA laws the maximum length of time John’s wife can exclude coverage to John is twelve months. Oregon is one of the highest paying States for Medicaid reimbursements.

Here is another comment that seems to bear out my suspicions that John can get treatment if surgeons believe it will help him. There may be details about his case that make success problematic; I note that Kristof did not speak to any doctors. One commented on the blog:

I was a physician who accepted Medicaid. They would pay me $120 for a bunion operation. I would have to pay for all the supplies, sutures, injectables and fixation devices. So if I wanted to use a titanium screw to fix the surgical fracture of bone necessary for the surgery, I would have to pay more for the screw set than the surgery paid. Plus the surgery included a 90 day global period. Meaning that the first 90 days I would receive no more fee than the original $120. And all of this because I chose to do the surgery in my off ice operatory rather than waste time admitting a patient to the hospital for a simple procedure under local. Health care reform needs to start in the doctor’s office and not in the insurance company’s bank account.

This entire debate is being conducted in an atmosphere of indignant evasion of reality. It seems that no one but the persons involved in actually treating patients are taking this seriously. The result is likely to be very bad. See also a neurosurgeon's comment here.

Mechanics I

Yesterday's GDP update for Q3 was more in line with what I had, and it implies that Q4 should show continued growth, and perhaps more growth than Q3.

So why am I so relatively pessimistic about 2010? Well, the first reason is compounded of some of the signs from Asia, which is improving. But growth in China is sustained mostly on a huge stimulus and a huge asset boom, and that has a known ending. Nor will it continue for years - by the end of 2010 some of their banks are going to be in trouble, and China's regulators are aware of the risks. Even rumors that banks will have to raise capital produce a massive fall in Chinese assets - so they appear to be in a tight spot.

Japan's growth is reported as good, but in nominal terms, Japan's economy is still shrinking. Workers' incomes have fallen 2.6% in nominal terms over the last year, and disposable income has fallen 2.9%. Of course CPI is falling as well, but their incomes are still declining in real terms, and the problem should be obvious. Singapore is not much better - take a look at the latest stats from Singapore and tell me what YOU think. I am not hugely bullish on Asia; India and China have maintained GDP growth with a lot of money infusions, but Chinese CPI is down, which makes me think they have a circulation problem. India is the bright spot, but they are now suffering inflation, especially in food.

Incomes are dropping quite hard in almost all of Europe's ring of fire. Ireland and Spain are in unambiguous depressions, as are some of the Baltics. The larger ex Soviets have experienced hard recessions, but one of the main future worries are that incomes are often dropping and there are a lot of foreign currency loans. Things will slowly improve on manufacturing, but those loans are a big worry for consumers; industrial production is no where near its former levels, and government debt is becoming an even bigger worry. Hungary is hard-hit, but Czech auto exports are falling, causing more concern, although by any measure Czech prospects for 2010 are better. Poland is the stand-out for 2009; the Polish economy generates pretty healthy internal demand. For a broader read on Europe, see the Q3 flash. Unemployment stats here. I am still working through Europe, so I don't have a conclusion.

For the US I have done much more, and I am still not very optimistic due to the basic mechanical structure.The problem is that our current downturn is most similar to the 79-82 period, during which the US went through two periods of declining GDP. Click on this graph and open it up in another tab or window.

Note the Fed Funds rate in the late 70s-early 80s graphed against the producer price index, the consumer price index and the unemployment rate.

Raising rates suppressed the underlying rate of producer price increases, which restored the ability of companies to make money. But it came at the cost of crushing credit (who can borrow at those rates?) and produced a very difficult recession with an extraordinarily high unemployment rate. However, once inflation had been crushed economic growth and credit growth could resume, and there was no protracted drag on the US economy.This graph shows how we got out of the 80s recession by looking at household sector debt (mostly mortgages at that time), housing starts and total gross private domestic investment. Debt is shown as the percent change from a year ago (left axis), and housing starts and GPDI are shown in units (right axis).

Because interest rates had fallen so sharply from their peak, housing affordability increased suddenly and very significantly, which sparked a round of building, which created jobs..... Etc.

This graph is the same as the one above but it includes the Fed Funds rate.

But we will not have the same dynamic this recession, because we are maxed out on consumer debt (even with a staggeringly low Fed Funds rate). Now we have to depend on the business sector or government for growth in GPDI, and it is hard for either to generate the same type of domestic boom.

Worse yet, if the Fed stops buying mortgage securities, mortgage interest rates are due to rise significantly. Also there is no doubt that mortgage lending standards will have to tighten; the agencies (especially FHA) are experiencing horrendous defaults. Low rates plus high losses = debt no one but the government will buy. And then those housing credits are due to expire....

So basically the housing outlook over the next couple of years is worse than it has been over the last few months. Beyond that, we can only hope for consumer boosts from must-have buying, irrational exuberance, or lower debt loads. Incomes are not increasing for most workers as tax receipts show; the retirement bulge is hitting; and overall taxable wages are still declining. There will therefore be only a marginal consumer pickup.

Needless to say no one is making a lot of money off interest. And worse yet, cost inputs for production are still rising. True, we have reached the Schumpeter turn according to tax receipts - corporate profits are rising - but will that provide enough carrying wave of growth to overcome the real income drops among consumers?

What you see in the latest update to CFNAI is a signal showing that the carrying signal is just not there:Compare the CFNAI signals from the 1980s downturn to our current downturn. The 1982 recession ended in November. (Recession dating, NBER)

These are the one month CFNAI indexes for the end of the 1982 recession:Nov: -1.03Dec. -0.77Jan. +1.37Feb. -0.66Mar. +0.83

Coming to the present:Now you will note that one month CFNAI has been headed down for a while, and the three month average has now followed.

Postulating that the current growth cycle started in June (many have it in July), here are the comparable months:May: -2.42June -1.81July -0.37Aug. -0.63Sep. -1.01And now October came in at -1.08. We just never climbed out of the hole.

The Fed can fiddle with the timing of the next leg down a bit, but it appears to be coming. Any theory (and it is the Fed's theory) that increased business profits will spark a slow steady growth cycle appears to be foundering on compressed business profit margins, meaning that many large companies are still cutting to try to bolster up profits. Because:Incomes are not rising (right scale, indexed to 12/2007) and real retail sales (left) are going sideways, and producer prices are slowly rising (right). This is not a recipe for profits, especially since the value of commercial real estate is dropping.

The next impetus that could really help us are consumer debt defaults and writedowns. Once people clear enough debt, they'll have more income left for other things. However that takes years, and the collapse in incomes (aggregate matters less than median) means that the go-to number keeps sliding down a bit.

If people can't spend from rising incomes, and if they aren't able or willing to borrow, and if input costs are rising, the only place companies can look for sustained growth is to external sales. It is not necessarily true that investment related to external sales will be put into the US, which means that GPDI probably will fall next year. And that is the horror scenario.

Friday, November 20, 2009

AGW Info Just Wants To Be Free

I'm still reading the healthcare bill, so I can't really read this massive group of files, but this is hawt:

From: Tom Wigley [...] To: Phil Jones [...] Subject: 1940s Date: Sun, 27 Sep 2009 23:25:38 -0600 Cc: Ben Santer [...] Phil, Here are some speculations on correcting SSTs to partly explain the 1940s warming blip. If you look at the attached plot you will see that theland also shows the 1940s blip (as I’m sure you know). So, if we could reduce the ocean blip by, say, 0.15 degC, then this would be significant for the global mean – but we’d still have to explain the land blip. I’ve chosen 0.15 here deliberately. This still leaves an ocean blip, and i think one needs to have some form of ocean blip to explain the land blip (via either some common forcing, or ocean forcing land, or vice versa, or all of these). When you look at other blips, the land blips are 1.5 to 2 times (roughly) the ocean blips—higher sensitivity plus thermal inertia effects. My 0.15 adjustment leaves things consistent with this, so you can see where I am coming from. Removing ENSO does not affect this. It would be good to remove at least part of the 1940s blip, but we are still left with “why the blip”.

The ah, implicit mind set is that they can do anything with the data they want - there is no respect for whatever the real measurements may be - but the result should be plausible.

In other words, there ain't no science in climate science. The reason for this attitude can be explained by the flood of grant money it produces. It is easy to believe anything when you get millions of dollars for believing it.

This is no surprise to anyone who has been watching the mutatis mutandis of official climate records over the last decade. It's merely very entertaining.

Langmuir's "Colluquium On Pathological Science" is online at this site, and may be relevant. This talk was given in the 1950s. I had heard about it and read an excerpt but I had never encountered the whole lecture. I got the link from comments on this Althouse post. Symptoms of Pathological Science:

The maximum effect that is observed is produced by a causative agent of barely detectable intensity, and the magnitude of the effect is substantially independent of the intensity of the cause.

The effect is of a magnitude that remains close to the limit of detectability; or, many measurements are necessary because of the very low statistical significance of the results.

Claims of great accuracy.

Fantastic theories contrary to experience.

Criticisms are met by ad hoc excuses thought up on the spur of the moment.

Ratio of supporters to critics rises up to somewhere near 50% and then falls gradually to oblivion.

Thursday, November 19, 2009

Senate Health Care Bill

Update: While I'm reading, go check out Carl at NOFP's post on how many Americans are really uninsured. I believe the data he cites to be good, and my conclusion on these bills has so far been that they would raise, not lower, the number of uninsured Americans. The reason for this is that they will all raise the cost of insurance and mandate additional coverage; the inevitable result will be that many Americans will lose coverage. End Update.

Patient Protection and Affordable Health Care Act, now substituted for the original text in 3590. You can read it here.

I copied the table of contents below. I am going to concentrate on the revenue section first. I highlighted all the sections I'm going to read with special attention.

Curiosity drives the interest in the hospice programs and the "nondiscrimination" provisions relating to assisted suicide (coverage?). Hospices that don't manage to shuffle their patients off to the mortuary have been under severe pressure lately; people think that hospices save a great deal of money, but they often don't. It will be interesting to see what they come up with next. My guess is they want 'em dead within two weeks. The problem is that sometimes terminally ill people recover on their own or experience substantial remissions, so the only way to accomplish the two week plan is basically to off the hospice patients by giving them enough drugs to suppress their breathing, knock 'em out, no liquids - they die quickly from pneumonia.